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Obstetric Cardiac Anesthesia with Andye Girnius · Style Points

• 0:00
  Hello anesthesia enthusiasts and welcome to another episode of Style Points. We'll start
• 0:14
  off with another RSI which of course stands for resident selected information. Today I'm
• 0:19
  here with Chris DiPietro, CA2 and incoming chief resident. Chris, what RSI do you have
• 0:24
  for us today?
• 0:27
  Today we'll be talking about neuroleptic malignant syndrome and serotonin syndrome.
• 0:32
  It's the dreaded one in a hundred thousand scenario. You induce a patient for general
• 0:36
  anesthesia using succinylcholine and propofol. Despite increasing your minute ventilation
• 0:41
  aggressively the untitled CO2 increases to 60 over the next 30 minutes and your patient
• 0:47
  becomes increasingly tachycardic. After placing the patient in the optimal position for surgery,
• 0:53
  you plug in the temperature probe to find the patient's temperature is 40.1 degrees
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  Celsius. You call for help and initiate treatment for MH. On the surface malignant hyperthermia
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  may be the obvious problem here but should the differential diagnosis stop there? Today
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  we're going to discuss the similarly presenting but less commonly thought of neuroleptic malignant
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  syndrome and serotonin syndrome. Neuroleptic malignant syndrome or NMS is a disease of
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  dopamine antagonism or depleted dopamine. Proposed mechanisms include disruption of
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  the nigrostriatal pathways in the CNS, mitochondrial disruption in skeletal muscle and dysregulation
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  of other neurotransmitters and catecholamines like GABA, serotonin, acetylcholine, and epinephrine.
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  The number one causes the use of first generation highly potent dopamine antagonists aka neuroleptics
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  such as haloperidol, a medication that can be used in the perioperative setting for agitation
• 1:53
  and postoperative nausea and vomiting. However, commonly used anti-medics such as metoclopramide,
• 2:00
  promethazine, and droperidol also work by using dopamine antagonism and can serve as
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  possible causes for NMS. Risk for developing NMS has been linked to higher doses of these
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  medications not necessarily the length of exposure. Other risk factors include surgical
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  stress, infection, dehydration, and existing use of lithium.
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  A commonly missed cause for NMS, which at its core is the state of a lack of dopamine,
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  are patients who are in withdrawal from a dopamine agonist such as a patient who receives
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  treatment for Parkinson's disease. NMS is a clinical diagnosis. Within 24 to 72 hours
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  of the use of the inciting factor, the onset of NMS usually follows a pattern of symptoms,
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  the first being mental status change such as agitation followed by possible stupor and
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  coma. This is often followed by so-called lead hyperagidity, hyperthermia, and autonomic
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  instability. Imagine now you have a patient under general anesthesia with these symptoms.
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  You do not have the ability to perform a mental status assessment so you are left with a patient
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  who has rigidity, hyperthermia, and autonomic instability. Sure sounds like something else,
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  right? The first step in treatment of NMS is removing
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  the offending agent. Discontinue all dopamine antagonists or replete with dopamine agonists
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  as needed. There are no evidence-based treatment strategies for NMS. Treatment such as diazepam
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  and dantrolene for skeletal muscle relaxation, and bromocryptine, amantadine, and levodopa
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  for dopamine repletion have only been successful in case reports. Further management is supportive.
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  Ensure a patent airway. Follow ACLS guidelines as needed for arrhythmias. Obtain adequate
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  IV access and consider invasive monitoring for hemodynamic trends and treat as needed.
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  Externally cool the patient. Labs should be sent to address abnormalities in electrolytes
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  and acid base status, myocardial damage, blood counts, kidney and liver function, and muscle
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  breakdown in the form of creatine kinase. If under general anesthesia, prompt discussion
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  with the surgery team about aborting the procedures should be had. Discontinuation of volatile
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  anesthetics and a switch to a total intravenous anesthesia should be considered. In the off
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  chance this is indeed malignant hyperthermia. Now serotonin syndrome, unlike NMS, is a syndrome
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  of excess. Specifically excess serotonin causing an excitatory state in the central nervous
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  system leading to both central and peripheral manifestations. Causes include overdose, inadvertent
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  drug interactions with two or more serotonin modulating agents, or even from higher doses
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  with a single agent. Classically, the cause of serotonin syndrome was excess serotonin
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  caused by monoamine oxidase inhibitor use when combined with an additional serotonin
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  agent such as SSRIs. While MAOIs such as selagelene and resagelin in the treatment of depression
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  have fallen out of favor, some drugs with MAOI properties remain clinically relevant.
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  While used for completely different reasons, linozolate is still a commonly used antibiotic
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  for multi-drug resistant organisms, and methylene blue is used for vasoplegia and hemoglobinemia.
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  More commonly used medications like fentanyl, moperidine, tramadol, odancetron, cyclobenzeprene,
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  and neuropathic agents like duloxetine and amitriptyline also modulate serotonin. St.
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  John's wort is an over-the-counter herbal supplement known for mood boosting properties
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  that also increases serotonin levels. Even illicit drugs such as prescribed stimulants
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  such as cocaine, amphetamines, and ecstasy are also common culprits. Like NMS, serotonin
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  syndrome is diagnosed clinically. Symptoms often arise within 24 hours following a change
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  to or the addition of a serotonin modulating drug. Symptoms commonly include agitation,
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  dipheresis, tachycardia, hyperthermia, tremor, hyperreflexia, and even sometimes rigidity.
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  The hunter criteria is a tool to aid in diagnosis. The hallmark of serotonin syndrome is clonus,
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  either spontaneous or induced. Again, imagine you have a patient under general anesthesia
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  with these symptoms, but you're unable to assess for clonus because you utilized a neuromuscular
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  blocker. Does this clinical picture sound familiar? Treatment involves prompt discontinuation
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  of all serotonin agents. Cases with mild agitation can often be addressed with benzodiazepines.
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  Moderate to severe cases may require aggressive sedation, ultimately endotracheal intubation,
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  and the treatment of hemodynamic instability. Cyproheptadine, a serotonin and histamine
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  antagonist, is typically reserved for patients for which benzos and initial supportive care
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  efforts fail. The remainder of treatment is largely the same as already discussed with
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  NMS. So the bad news is these disease present similarly, especially under general anesthesia.
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  The good news is these diseases remain extremely rare, but they almost always occur in an unpredictable
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  fashion. That is why as perioperative providers, it is imperative that we take a deep dive
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  into our patients' recent medication use before they undergo anesthesia. If your patient
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  with Parkinson's received three doses of high dose haloperidol for agitation the day
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  prior and has not received their dopamine agonist for several days, take note of this.
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  If your patient undergoing a CABG is on two serotonin agents for depression and methylene
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  blue is used on cardiopulmonary bypass for vasoplegia, again, take note of this. As always,
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  use your best clinical judgment, but don't be afraid to ask for help from a colleague.
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  Chris, thank you so much. Joining us today is Dr. Andi Gernius. Andi is the division
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  director of obstetric anesthesia and the fellowship director for obstetric anesthesia fellowship
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  here at the University of Cincinnati. She completed dual fellowships in both obstetric
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  and cardiac anesthesia and continues to practice in both domains. She also has a lot of cool
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  tattoos and a fearless attitude. Andi, thanks for joining us.
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  Thanks for having me. Andi, to start, I'm going to ask you one of
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  the standard get to know you questions. If you could invite anyone in the world over
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  for dinner, including somebody from the past or even from fiction, who would you invite
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  and why? I always struggle with this question. I think
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  because deep down I'm afraid that I'm really boring and I wouldn't be able to talk to any
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  of these people. That's fair.
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  But I think that the person that I would love to talk to most is Adam Grant. You are familiar
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  with him. But for those who aren't, he is an organizational psychologist at Wharton
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  at the University of Pennsylvania. And he does a lot of work on change psychology, leadership
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  psychology. And I find his ideas really interesting and very applicable to what we do in healthcare.
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  So what would you want to ask him about? What would you serve an organizational psychologist
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  for dinner? Well, God, that's a great question.
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  I'm always afraid people are judging. But no, I just I would just love to have a conversation
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  and see where it goes and just how he comes up with the ideas he comes up with and where
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  he finds all of his stuff. And honestly, he seems like just a pretty cool guy.
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  That sounds great. Thanks for sharing. The next thing I'd like to ask you about, could
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  you talk a little bit more about your background? How did you come to specialize in obstetric
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  cardiac anesthesia? Yeah, it's not it's not the most obvious
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  combination, is it? But it was kind of an accident. Actually, during residency, I was
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  very much on a cardiac track. I wanted to do the cardiac fellowship. I loved cardiac.
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  It was the thing for me, you know, I liked OB, but I didn't really see it as like a fellowship
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  type career. It was just something that I did in residency and learned about. And about
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  two months before the end of my residency, we had a patient admitted who had basically
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  a tamponade physiology. And she was also about 34 weeks pregnant with twins. Wow. And and
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  at the time, an unspecified number of years ago, cardiac obstetric anesthesia was just
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  not really a thing, right? Cardiac and OB didn't really go together. The cardiologists
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  were all freaked out that she was pregnant. Like they wanted to be very hands off. They
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  didn't want to do anything. The obstetricians were very freaked out by this heart condition
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  that they really had no idea what to do with. And I happened to be the resident on when
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  she was admitted and saw her multiple times, did her anesthesia for her delivery. So I
• 11:04
  kind of got to follow her more than we do for most people. And what I realized from
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  this is that we actually know about both of those things, right? We learn about a broad
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  set of specialties in our residency. So we know about OB and we know about cardiac. And
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  we could probably get to the point where we could combine them and figure out what to
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  do in a way that the other people seem to be struggling with a lot more because it had
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  been a lot longer since they had had to really deal with any of this information. And so
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  that's when it started to occur to me that there could be a role for us in the care of
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  these patients and really connecting these things and managing them through delivery.
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  It seems like you really got to serve as the connective piece in that situation and you
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  decided to make a whole career out of it. Yeah, it really was kind of a light bulb in
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  my head. It stuck with me a lot. I ended up presenting that patient to our entire department.
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  I still remember. I remember it really clearly. It's one of those things that just sticks
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  with you and you could just remember it clearly like it happened yesterday. And it really
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  changed the course of what I decided to do with my life and career. A lot of people think,
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  oh no, a pregnant patient, that's a little scary. Or they also think that about the pregnant
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  patient with cardiac disease. Oh no, that's a little scary. But you take both of those
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  head on. So what are some of the biggest challenges that you face in managing these pregnant patients
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  with cardiac conditions during labor and delivery? Well, the first thing is that all the things
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  you said about being scared of those patients, I still am too. Even though I've done them
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  a lot and I'm more comfortable than a lot of people, when we're delivering the really
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  sick ones, I am still scared because there's only so much you can do. So I don't know if
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  that helps other people to know that. But no, it's really interesting. The more I've
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  done this, some of the challenges in the beginning were more figuring out what the right thing
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  to do was, what the right anesthetic was, how to keep them stable, what the right meds
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  were to use. And I've really gotten more comfortable with that part of it. And a couple of the
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  things that have really come out more recently are deciding how much extra a person needs.
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  You have your basic labor and delivery, your basic monitors, your basic things. And that's
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  a normal childbirth experience. Because you have to remember that in the end, these women
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  are having babies and people tend to see that as a life experience a little bit less than
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  a medical intervention. And some of these people with heart disease need more medical
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  intervention. They need more care. They need ICU admission. They need different things.
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  But that has implications for their childbirth if they can see the baby afterwards. From
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  the ICU, they can't see their baby afterwards. So that is a huge thing for a lot of people.
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  Do they need invasive monitors, which dictates where they can deliver in your system. And
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  so they're the people who are very low risk that can have the quote unquote normal experience.
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  They're the people who are very high risk, where it's kind of a no brainer to do all
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  the things. But some of the people in the middle, it's a little tricky to decide how
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  much they need, how much to completely change the experience, how much to take them outside
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  of our normal routine. Because I think we also forget that there is some risk to people
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  in altering our normal routine. If you take a delivery patient outside of labor and delivery,
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  everyone gets a little freaked out about that. You're further away from your typical equipment,
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  your typical meds, the people who know how to deal with that part of things. And so that's
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  not benign either. And so that's a little bit of a tricky thing, right? We've had some
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  recent patients that I think we've either probably over treated or we kind of took a
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  risk on and pushed people's comfort level a little bit. And that's been a tricky thing
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  to figure out.
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  So it sounds like we really need to decide which category of risk these patients fit
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  into. So when we're doing that preoperative assessment of the pregnant patient with a
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  cardiac condition, when does that start and what are you looking for?
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  Yeah. Well, when we evaluate people, we try to do it all as a group, right? So we have
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  a multidisciplinary clinic with cardiologists, maternal fetal medicine doctors, and anesthesiologists.
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  And one of the big ways that we risk stratify people is by using one of the risk assessment
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  scores. It turns out there are actually several for pregnant women with heart disease. And
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  the one that we tend to use most commonly is the World Health Organization. It's a numerical
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  score from there are five total categories. They go from one to four, and it's based on
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  their underlying cardiac lesion and how well or poorly that lesion would be expected to
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  tolerate pregnancy. And that really just gives you their overall risk for all of the pregnancy
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  and peripartum period. It doesn't really nail down kind of what you need to do in the hospital.
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  And so if we're trying to figure out kind of what we think is going to happen around
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  delivery, right, we look at how they've done during pregnancy, how their hearts tolerated
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  pregnancy, their serial echoes, what's happened with that, what their volume status looks
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  like. Basically, what I want to know is how well is their heart going to tolerate the
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  stress of either labor or a C-section and that auto transfusion that comes with delivery
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  because that's a big volume bolus for some hearts that may not be able to handle it.
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  So those are kind of the questions that I'm thinking about in my head. And I'm trying
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  to think about how much room they have in their vasculature, right? If they're over
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  a liter already or if they can tolerate that. And that really dictates kind of which direction
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  I might go with my anesthetic and how we might approach their care after delivery.
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  So how often are you meeting with these patients? How does that multidisciplinary clinic work?
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  So we have the clinic once a month. And some patients are coming every single month. If
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  we think they're very high risk, we want to keep a very close eye on them. And in between
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  those appointments, they can also go to the high risk OB clinic, which is once a week.
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  So the MFMs are seeing them a lot. There are some people who come to the clinic once and
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  we say, things look pretty good. We think you're fine. And some people even come from
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  other hospitals. They come from our community hospital, Westchester, and we say, you're
• 17:03
  so low risk, you can deliver there. You don't need to be here. These are our recommendations
• 17:07
  in general. And then you can go forth and give birth wherever you want. And some people
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  kind of come once every three months or once every trimester, or we see them once and then
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  we get like a third trimester echo and they follow up. So it really depends on what we
• 17:19
  think their overall risk is.
• 17:21
  Makes sense. So let's say that somebody comes in to the hospital and they haven't gotten
• 17:27
  any care beforehand. This is probably a situation that you've never seen before. What's going
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  to be your approach towards the general history and physical of this patient? How are you
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  going to optimize them in the brief time period that we have before they deliver?
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  Yeah. So I think that the most common scenario for this is somebody with peripartum cardiomyopathy.
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  This is somebody who doesn't actually have any heart history and they develop heart failure
• 17:56
  during their pregnancy, kind of near the end. And so you could approach it kind of the same
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  way you would approach any heart failure patient, right? You figure out their symptoms, you
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  figure out their volume status, you know, you assess their fetal status and, and figure
• 18:08
  out if there's anything urgent that needs to happen there because of the fetal status
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  is not reassuring, then that changes your timeline a lot. And that's one of the big
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  determinants of things. So you, you know, you get your history, your physical, your
• 18:19
  timeline of symptoms and, and usually they're going to get an echo. And so you really want
• 18:24
  to know what that looks like. And, and you have team meetings. You get together with
• 18:29
  everyone who's taking care of them and you all talk through what the timeline is from
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  a fetal perspective, from a maternal perspective. And how can you balance, you know, the need
• 18:39
  to optimize mom and the need to deliver a baby that may or may not be doing well, depending
• 18:44
  on how mom is doing.
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  A lot of the medications that we would typically use on a cardiac patient might not be so good
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  for a fetus. So how do you navigate that space when you're talking about the risk to mom
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  versus the risk to baby?
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  I mean, I think that our overall guiding principle is that a stable mom equals a stable baby.
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  And so there are certain medications that we all kind of know to avoid, right? The ones
• 19:13
  that are bad in pregnancy, the statins, the coumadins, you know, a tunnel all which randomly
• 19:18
  among beta blockers is terrible for babies, apparently. And so we make sure we're avoiding
• 19:22
  those things. And all the other things are really okay for use in pregnancy with certain
• 19:28
  caveats, right? So for example, Lasix, right? When you have a heart failure patient, you
• 19:32
  would need to diaries. That's okay in pregnancy. It has some risks to the baby, right? It can
• 19:39
  lower their fluid. It can cause, you know, certain other things. And so they just get
• 19:42
  monitored more frequently to make sure that their fluid levels are doing okay. But we
• 19:46
  actually give it quite commonly when it's needed for our heart patients. Same thing
• 19:50
  with other beta blockers like metoprolol and lobatolol and things like that. We actually
• 19:54
  use those pretty commonly because we think that optimizing mom and making her the best
• 20:00
  she can be is what's going to help baby the most anyway. And those drugs with monitoring
• 20:05
  are actually pretty safe.
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  The other day, I remember you staying late just so you could deliver one of your favorite
• 20:14
  lectures on what to do with a variety of lesions in the pregnant patient. And I wonder if you
• 20:22
  could talk a little bit about that, since I know it's one of your favorite topics. What
• 20:28
  should we how should we think about the different cardiac lesions and how they apply to a pregnant
• 20:34
  patient and you don't have to give the entire one hour lecture?
• 20:37
  Well, I can do it in less than an hour. Okay, I've had to do it in 15 minutes before it's
• 20:42
  not quite as good without my without my diagram. Sure. But basically, my philosophy is that
• 20:50
  there are all these fancy risk scores that will tell you who's going to do badly during
• 20:54
  pregnancy, who's going to struggle. But I believe that if you look at the physiology
• 20:57
  of the certain lesions, you can predict that on your own anyway without these risk scores.
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  And the risk scores actually do bear a lot of that out. And so as a resident, I remember
• 21:09
  being in the OR and getting a table that on one side had all the valvular lesions, you
• 21:14
  know, aortic stenosis, mitral stenosis, the regurginant lesions, Hocum, and on the other
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  on the top of the table was loading conditions for the heart. And what the optimal loading
• 21:24
  conditions were for that lesion. So preload, afterload, heart rate, contractility, and
• 21:29
  you had to say what you thought was best for each one of those things for each cardiac
• 21:34
  lesion. Those are your anesthetic management goals, right? Those are your hemodynamic goals
• 21:38
  in the OR for that lesion to maximize cardiac output.
• 21:42
  Okay, so get out your pencils, paper, everybody go ahead and draw that out before you listen
• 21:47
  to the next part of the podcast.
• 21:49
  So I have our residents, we draw it out on the board. And you know, we say, for example,
• 21:56
  a stenotic lesion, whether it's aortic stenosis or mitral stenosis, right, you want your heart
• 22:00
  rate to be low to increase your diastolic filling time for a stiff heart, right? You
• 22:06
  want your preload to be I mean, relatively even, but you don't need it to be like so
• 22:14
  a volume overload, you need enough left atrial pressure to have forward flow, but you don't
• 22:18
  need a ton of volume because you have a stiff heart and you don't want it to back up. You
• 22:22
  want your afterload to actually be maintained to high because you want to maintain coronary
• 22:26
  perfusion, for example, and your contractility again, you want to maintain it because you're
• 22:30
  pumping against a stenotic lesion, right? Those are your anesthetic goals. Those are
• 22:35
  the things that are good for that lesion that are not going to get you into too much trouble,
• 22:39
  right? For regurgitate lesion, it's kind of the opposite. So if you've heard the fast
• 22:42
  flow forward mnemonic, right, you want a higher heart rate, you want more volume because I
• 22:48
  think of regurgitate lesion says there's all this extra volume swirling in the heart. So
• 22:51
  you need a little more volume in your body to kind of make up for that. So you want your
• 22:55
  volume to be up. You want your contractility to be maintained, you want your afterload
• 23:00
  to actually be low so that more blood goes forward than backward. Then, if you add another
• 23:06
  line to your table called pregnancy, and you fill in the physiologic changes that happen
• 23:12
  during pregnancy, you can actually compare what happens during pregnancy to what's best
• 23:17
  for each lesion, right? So pregnancy, right, your heart rate goes up, your preload goes
• 23:22
  up by a good amount, your afterload goes down, and your contractility is maintained. Your
• 23:27
  heart does die a little bit, but your contractility is maintained. So if you look at your chart
• 23:31
  and you have all those things filled out, what you'll see is that the stenotic lesions
• 23:35
  are basically the opposite in every category, whereas the regurgitate lesions all line up
• 23:39
  pretty well. The things that are good for regurgitate lesions are the things that are
• 23:42
  happening to pregnant patients. And sure enough, they tend to do better during pregnancy.
• 23:47
  So if you are looking through a patient's echo and you see stenotic lesions, that's
• 23:52
  going to cause more of a cortisol surge for you. Absolutely. Than if you saw a regurgitate
• 23:57
  lesion. That's good to know. Okay. So what kind of monitoring techniques do you use for
• 24:04
  these patients when they're on labor and delivery or when they get into the operating room?
• 24:11
  What do you think is the most helpful? So the first thing that you have to know is what
• 24:16
  monitors your labor and delivery can support. So for example, on our labor and delivery,
• 24:22
  we can't have an arterial line in a laboring patient because the nurses on L&D, while they're
• 24:27
  very good at many things, are not really trained and experienced to manage arterial lines.
• 24:31
  They don't know how to do it. They don't know how to use the tubing. That is not our lane
• 24:37
  and we do not want anything to do with it. And so we can't have that. If we think that
• 24:41
  a patient needs that level of monitoring, they have to labor in the ICU. And we have
• 24:46
  had patients labor in the ICU. They do not love it.
• 24:50
  I have dealt with one or two of those on call myself.
• 24:53
  Nobody really loves it, which is another challenge, right? Coordinating a delivery like that in
• 25:00
  a patient who's in a very unfamiliar location.
• 25:02
  Yeah, absolutely. So how do you approach monitoring a patient that is so far away? What are your
• 25:11
  goals there?
• 25:12
  Yeah. One of the things that we are lucky to have is a cardiac ICU in which we have
• 25:17
  an anesthesia critical care team who has somebody there 24-7. And so over time, the agreement
• 25:23
  we've come to is that those laboring patients who are in the ICU, right, our anesthesia
• 25:26
  critical care team is kind of the primary ICU team for that person. They're the ones
• 25:31
  who are monitoring the hemodynamics so that our labor and delivery anesthesia team who
• 25:34
  is three floors away doesn't have to dedicate someone to be up there all the time. So we
• 25:39
  are monitoring the labor of a girl, which is checks every several hours. And the critical
• 25:45
  care team can call us if they have any questions or concerns, but we have them kind of as partners
• 25:49
  who help us with the management of that.
• 25:52
  A lot of these pregnant patients with heart conditions are anticoagulated. How do you
• 25:58
  approach the idea of sticking a big needle in their back to do an epidural when they
• 26:04
  might need anticoagulation to prevent them from getting some horrific blood clot?
• 26:09
  Yeah. That is always a tricky scenario. Thankfully, most of the patients who are pregnant are
• 26:16
  on lobenox. Lobenox is pretty standard for pregnant patients and ASRA has pretty clear
• 26:20
  guidelines about stopping lobenox before noreaxial techniques. And so, you know, we're usually
• 26:28
  able to plan their inductions in a way that allows us to do noreaxial just like we would
• 26:33
  anyone else who's on anticoagulation during pregnancy. That's not so much different. In
• 26:37
  the rare case that they are on Coumadin, that's a lot trickier. I've had maybe two of those
• 26:41
  cases in my career. And we had a recent one where the patient was at such high risk for
• 26:46
  thrombosis that she was bridged on a heparin drip and nobody felt comfortable turning off
• 26:51
  her heparin drip until just before the surgery. And so she actually had to undergo general
• 26:55
  anesthesia for her C-section because we were not able to stop her anticoagulation.
• 26:59
  Wow. But it seems like that's a little bit more of a rare scenario versus most of the
• 27:03
  time you just follow the ASRA guidelines.
• 27:05
  Exactly. Most of the time you're dealing with a standard lobenox dosing, standard lobenox
• 27:09
  guidelines and the OBs want to stop anticoagulation for delivery.
• 27:13
  That makes sense. So after one of these babies has been delivered, the risk to mom doesn't
• 27:20
  go away. Can you talk a little bit about what common pitfalls you might see right after
• 27:26
  delivery for these patients?
• 27:28
  Yeah. So as you probably have learned at some point, the maximum cardiac output that these
• 27:34
  patients are going to see is really right after delivery. And for a long time, I thought
• 27:38
  immediately after delivery meant like the instant the baby was delivered. That's when
• 27:42
  it was going to happen. And I've learned through time that is not really true. In C-sections,
• 27:48
  what I've noticed is probably about 10 to 15 minutes after the baby comes out is when
• 27:53
  I would start to see signs of that volume hitting their heart if I didn't do anything
• 27:56
  about it. So the patient gets more short of breath, the pulse starts to go down. Like
• 28:01
  you just, the blood pressure gets a little soft. You just start noticing them wobbling
• 28:04
  a little bit. And so from, from that point on, that's when you really start to have to
• 28:10
  worry about a big bolus of fluid hitting the heart all at once. Even if they make it through
• 28:14
  that, the day or two after delivery is when all the other fluids they've gotten that have
• 28:20
  seeped into their tissues, all the swelling they've had, that all starts to mobilize and
• 28:23
  go back into their circulation. And so you can actually get delayed reactions, um, a
• 28:28
  couple, up to a couple of days later. And so for some of the patients we're really worried
• 28:31
  about, we'll just keep them on the hospital maybe for an extra day, just to keep an extra
• 28:35
  close eye on them, to make sure that they've started to kind of mobilize their fluid. You
• 28:39
  know, you can tell their urine output picks up. They start to feel the swelling go down
• 28:42
  and know that they're doing okay with it.
• 28:46
  Many patients come to OB with a birth plan in mind. And a lot of times anesthesia has
• 28:54
  a lot of specific roles to play or not to play in that birth plan, which as opposed
• 29:00
  to general anesthesia, people don't usually come to us with an anesthesia plan. So how
• 29:05
  do you navigate patient preferences when they might not be aligned with the standard of
• 29:12
  care?
• 29:14
  So this is tricky and it's, it's interesting to talk about because I'm like anybody else.
• 29:22
  Some days I try really hard to have this conversation and I do a terrible job at it and people just
• 29:30
  dig in their heels and it's awful. And some days I do a really great job. I'm like, I
• 29:34
  did everything right there. But my favorite thing to do, if I can get it right, is to
• 29:42
  go in and say, look, like you have this whole plan for how you want things to go. And I
• 29:46
  know that you've thought a lot about it and you've done research and you've read a lot
• 29:50
  of things and you decided this is the thing that I want. But there are things about this
• 29:55
  whole experience and about you specifically that you're not going to find in your internet
• 30:00
  searches. You're not going to find in the books you can read or the books you can find
• 30:02
  because they live in my head and they live from my experience and taking care of patients
• 30:06
  like this and doing this over and over. And so as you think about how you want this labor
• 30:11
  to go and as things progress and change through the day, I want to give you this information
• 30:15
  that lives in my head that you can take into account. If you start thinking about how you
• 30:21
  want the state to go and if you want to reassess, change your plan or whatever, I want you to
• 30:24
  have all that information as well.
• 30:27
  That makes a lot of sense. It's always nice when you have some go-to lines that you can
• 30:31
  use for patients, you might have an expectation that's different than the reality.
• 30:35
  Yeah. And I mean, honestly, I think the best you can do is hear what they want and why
• 30:42
  they want it and make sure that they know that they're being heard and that we're not
• 30:47
  just saying like, this is how it has to go and I don't care what you think, but to at
• 30:51
  least like live with what they want and say, these are the reasons that I want it to be
• 30:55
  the way that I want it. And that, you know, sometimes we can compromise with what you
• 31:00
  want and sometimes it really is just a safety thing that we can't compromise on and I will
• 31:04
  do my best to compromise where I can.
• 31:06
  Yeah, that makes sense. So, zooming out a little bit, what sort of recent advancements
• 31:13
  or research finding in obstetric cardiac anesthesia do you find most exciting or promising? What's
• 31:19
  the new frontier of what we're doing for these people?
• 31:22
  So a lot of what you will read right now about cardio obstetrics is the concept of the cardio
• 31:26
  obstetric team. The cardio B team is the big thing people are writing about. And really,
• 31:31
  it's just the idea of multidisciplinary care and coordination and kind of having a formal
• 31:35
  team or structure to evaluate and care for these patients and having a team who's experienced
• 31:40
  in these patients. So it basically functions as a referral center, just like any other,
• 31:45
  you know, uncommon common uncommon condition, basically, where you go someplace where people
• 31:50
  have done this before they have a system in place, they know what to do. Even if they
• 31:53
  don't, they know how to think through the situation together. And so you want to make
• 31:58
  sure right you have obstetricians, MFMs, cardiologists and anesthesiologists, obstetric or cardiac,
• 32:05
  because most places don't have both right there are not a lot of people who do both
• 32:08
  of those things together. And then you want to make sure you have your people identified
• 32:12
  who are not needed for every case, but you have to maybe call into action sometimes cardiac
• 32:16
  surgeons, electrophysiologists, critical care, you know, just all the other ancillary services
• 32:23
  that might have to be involved with these people. And so that's really the big thing
• 32:26
  is trying to get those formal systems of care to take care of these patients. What I would
• 32:32
  like to see going forward is, and this is giving me ideas is kind of what I mentioned
• 32:39
  earlier, right around delivery, who do we need to escalate care for who's going to struggle
• 32:43
  specifically so much with delivery, because the one drawback with these risk scores is
• 32:48
  that it doesn't tell you who's going to struggle at that particular time. It just kind of tells
• 32:52
  you your overall risk of having something happen at any point. And so if we can nail
• 32:56
  down and we can look back and say who actually did end up struggling with their delivery
• 33:00
  who did end up having trouble in those first couple postpartum dates? Could we actually
• 33:05
  have a little more data behind that decision of who needs more monitoring who needs to
• 33:09
  deliver in a special place? I think that would be really helpful. Yeah, that does sound like
• 33:14
  an interesting project. Do you want to give that your email address so that people can
• 33:19
  volunteer to be part of it? I'm always I'm always happy to work with people who are interested
• 33:24
  in projects. So let's say that somebody has listened to this podcast and they want to
• 33:29
  be you. They're really excited about obstetric cardiac anesthesia, and they want to get cool
• 33:35
  tattoos and everything else. What advice would you give them? What would you tell them? How
• 33:40
  can they structure their career maybe starting from medical school, aiming towards a career
• 33:47
  in obstetric cardiac anesthesia? Well, I'm not sure you have to structure things quite
• 33:52
  as early as medical school. So deciding on anesthesia is a good first step. But when
• 33:56
  I think back to medical school, I remember liking my OB rotation even then. And so what
• 34:02
  I would say is pay attention to the things that you're enjoying in the subject matters
• 34:05
  that you're enjoying, because you don't have to do that specialty to be involved in that
• 34:09
  specialty. And I don't think I realized that back then. The nice thing about anesthesia
• 34:14
  is that you can be adjacent to a lot of fields and kind of still be involved in without primarily
• 34:18
  doing that thing. I don't have to be a cardiologist to be involved, right? Like I do cardiac anesthesia.
• 34:24
  I'm certified in echocardiography. I don't have to be a cardiologist and see patients
• 34:27
  in clinic. That's great. So if you're interested in anesthesia, the you know, a nice thing
• 34:34
  in med school is just kind of pay attention to the other things you did enjoy and see
• 34:37
  if there's a way to incorporate that in your career in anesthesia. There's a lot of flexibility
• 34:41
  in that way. And if you are specifically interested in cardio OB, see if you have a clinic where
• 34:47
  you are. See if you can shadow somebody who actually does it. See if you can see a little
• 34:51
  bit about what the care system looks like where you are. Get an idea of it's something
• 34:55
  you might be interested in doing. Because I really like what I do. It's such a niche
• 35:00
  thing that I get a lot of phone calls like I'm a resource for people. And that's really
• 35:05
  cool. It sometimes can cut into your off hours because not a lot of people have the knowledge
• 35:10
  that you have. But it's not too bad. And enduring residency, you know, really first focus on
• 35:16
  being a good anesthesiologist. Focus on learning how to build relationships, working among
• 35:22
  a team, you know, pay attention to obviously those two rotations that you're going to do
• 35:26
  well with. But the best thing you can do is be good at your job, your basic job. And then
• 35:34
  as far as pursuing both fellowships, the good news is at least among the obstetric anesthesia
• 35:42
  world, there's a lot of interest in doing both of these things. And so there's a lot
• 35:46
  of support in that way to try to make it happen. People are actually really excited about it,
• 35:50
  which is funny to me because when I was doing it, everyone thought I was crazy. This is
• 35:54
  unheard of. People are like, why are you doing this? Doesn't make any sense. And now it's
• 35:58
  really a thing that people are doing. And so there's an effort to try to like dual
• 36:03
  match into fellowships. Cardiac is a little more competitive. So that can be the tricky
• 36:08
  one. I would focus on making your application good for that. Obstetric anesthesia is a wonderful
• 36:15
  specialty, but not nearly as competitive. If that's helpful. I don't know.
• 36:20
  That makes a lot of sense. Is there is there an order in which you recommend doing the
• 36:25
  fellowships? Should you get into cardiac because it's the tougher one to get into first? What
• 36:29
  do you think? So what I have heard people talk about is the worry from a program director's
• 36:37
  standpoint is that people are going to try to get into this dual matching thing and get
• 36:42
  into the OB fellowship as like a backdoor to get into cardiac. And so a lot of places
• 36:46
  will actually want you to do the obstetric fellowship first interest to make sure you
• 36:50
  really want to do it and not get in, do the cardiac fellowship and then be like, actually
• 36:54
  I don't want to do OB anymore. I don't know how much that's actually happened. I think
• 36:58
  that's just a fear that people have because cardiac is so much more competitive that they
• 37:03
  don't want to end up getting taken advantage of. So I I'm not sure how much choice you
• 37:07
  would have in that, to be honest. Okay. So lastly, let's wrap up talking about
• 37:13
  some style points. What style points or points of personal preference have brought you success
• 37:19
  in your career, both in and out of the operating room?
• 37:23
  So for me, this will not surprise you at all. But communication is a big one. And it's something
• 37:30
  that I've become more formally interested in recently, but realized that I've really
• 37:34
  done my entire medical career. As an intern, I realized that female physicians and female
• 37:41
  nurses had a little bit of a different relationship than our male counterparts. And I realized
• 37:47
  that I was going to need to be a little bit more deliberate about building a relationship
• 37:53
  with nurses so that when push comes to shove, right, if you're in an emergent situation,
• 38:00
  emotions are high, tempers are high, you give an order, you're not misinterpreted, right?
• 38:05
  You like you're a known person to these people. It goes very, very differently than if you
• 38:10
  just kind of come in, you give orders, you're dismissive or whatever. You don't have any
• 38:15
  like social capital, or lack of a better word. And so I started doing that then. And, and
• 38:23
  I've just kind of kept doing it, right? It's nothing crazy. It's nothing sinister. It's
• 38:27
  literally just stopping for a moment to chat with people asking their opinion, you know,
• 38:31
  giving where you can give like if they're like, Hey, I think this is a better way. And
• 38:34
  it doesn't make a difference to you. Great. That sounds good. Especially as an intern,
• 38:39
  nurses have so much to tell you. They know a lot more about actually taking care of patients
• 38:43
  than you do when you first start. Absolutely. So anyway, communication, building relationships
• 38:52
  with people you work with, and honestly, just getting everyone in the same room to talk
• 38:56
  about stuff. That's the best thing about our cardiac OB clinic is that we spend the first
• 39:01
  hour all sitting in a room together and going through all the patients and making their
• 39:04
  plans, which can change when you see them. But we're all just talking to each other in
• 39:09
  the same room. There's no messages going back and forth in the chart. There's no like phone
• 39:13
  tag. There's no, okay, well, I talked to this person, I talked to the other person and call
• 39:17
  you back. Like we're all just talking in a group. That can make a big difference when
• 39:21
  you bring all the experts into a room. It seems like you could come to a consensus much
• 39:25
  more quickly. And by reading people's faces, you can probably see which points are more
• 39:31
  or less important and where we can make compromises. Yeah. And I, um, I bring residents to the
• 39:36
  clinic, not because I think everyone is going to be interested in cardio OB anesthesia,
• 39:41
  but because I actually want them to see what that looks like, what that whole conversation
• 39:46
  with everyone in a room, how constructive it is, how easy it is to come up with a plan
• 39:51
  that way. And almost universally, despite any skepticism going into it, they find it
• 39:57
  to be a very positive experience. They think it's cool. They learn a lot. It helps that
• 40:02
  I don't make them write a lot of notes. But, um, but no, I think that they, they enjoy
• 40:08
  the experience and seeing what it's like. And, you know, even beyond a formal clinic,
• 40:13
  when I'm on the OB floor and we have a question about something, I'll just go to the OB residence
• 40:17
  to the bubble where they do all their work and I'll just sit down and I'll be like,
• 40:21
  Hey guys, what's up? And we just talk and then I'll just stay and chat with them for
• 40:25
  a few minutes. And I think that's really helped how I interact and work with them. And in
• 40:30
  general, other people on that floor. Well, those are very helpful. And I think that can
• 40:36
  be appreciated no matter what flavor of anesthesia you do. Yeah. I think that's pretty much a
• 40:40
  universal concept in life that will help you anywhere. Andy, thank you so much for joining
• 40:46
  us. Thank you for having me. And that's it for this episode of style points. Now I've
• 40:52
  deliberately increased the difficulty level of liking subscribing or leaving a review
• 40:57
  of the podcast. So I don't actually think you'll be able to do any of those things.
• 41:02
  Or am I just using reverse psychology or maybe double reverse psychology? Is anything peel?
• 41:11
  Do any of us exist beyond this current moment? Okay, we're all done. Open your eyes.